DESCRIPTION (As Adapted from the Investigator's Abstract): By the year 2020, 2.5 million persons over the age of 65 will die annually in the United States and approximately 40% of these deaths will occur in nursing homes. Death is part of the fabric of the nursing home culture, yet little research has evaluated the quality of care at the end of life. The purpose of this in-depth study is to describe comprehensively the process of care for chronically ill, declining nursing home residents and the outcomes of this care, using both quantitative and qualitative methods. The specific aims are to: (1) describe the processes of care (e.g., pain and symptom management and advance care planning) for chronically ill, declining nursing home residents; (2) explore the relationship between these processes of care and two quality outcome indicators (e.g., resident and family satisfaction with care and quality of life prior to death); and (3) characterize features of the nursing home system (e.g., staff sensitivity to ethnic diversity, care planning process, staffing levels) that facilitate or impede the processes of care associated with positive outcomes. Two diverse nursing homes have been selected purposefully for this study. One facility has a community reputation for providing targeted, high quality end of life care and the second provides more traditional care. Residents will be selected based on 3 criteria: (1) primary diagnosis of a chronic illness as opposed to cancer; (2) declining, post-admission changes in the resident's condition, including ADL decline, weight loss, falls, personality change, disengagement, increase in infections, increase in hospitalizations, decrease in cognition; and (3) National Hospice Organization's Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases. A triangulated descriptive, correlational design is proposed in this study. Data collection will include a focused ethnography (participant observation, formal and informal interviews), questionnaire data, and medical record review. Data analysis methods will include descriptive statistics, Pearson Product Moment correlations, repeated measures MANOVA, and qualitative content analysis. The use of triangulation will strengthen the comprehensiveness of data collection, allow for the comparison of findings from both quantitative and qualitative data, and ultimately enhance the validity of the findings. The proposed study will address major gaps in the literature by evaluating processes of care for chronically ill, declining nursing home residents from the perspective of residents and their families, and the relationship of these processes to quality outcome indicators.